Since I tend to report on aspects of my personal life, I want to announce some personally exciting news: My daughter and her two small children moved to LA for a year. Not only are they living three minutes away…the children are in my temple school. I am delighted!

I have also become involved with a terrific organization, the National Breast Cancer Coalition (NBCC) which sponsors and supports the research that will help us prevent, diagnosis and effectively treat breast cancer. They are holding their annual event in LA on October 6. It will be a phenomenal French style review of dancing and singing titled “Les Girls” with performances by many of your favorite TV and theater stars and will be hosted by Allison Janney (who, I might add just won two Tonys). I am somewhat embarrassed to add that the NBCC board decided to present me with an award that evening and I am truly honored.

So if you think you would like to come to a fun evening and contribute to an important cause you can download details HERE.

Now onto the medical subject of this week’s website….Weight Loss

The September 3 issue of JAMA was dedicated to this weighty subject. As you know, one third of Americans are overweight or obese. It truly is an American epidemic. (And by the way, risk for a majority of cancers is significantly increased or just plain caused by obesity.) Multi billions of dollars are spent on branded weight loss programs, foods, diets, lifestyle recommendations and “come-on books” that suggest a secret way to lose pounds quickly, now and forever… A meta-analysis of 48 unique, randomized trials was published in that issue of JAMA and after many tables and graphs concluded that both low-carbohydrate and low-fat diets were associated with more weight loss than no dietary intervention over a 12-month period and that behavior support and exercise enhanced weight loss. (So far, I think we all knew this.) What made this article unique and caused it to create a stir was the fact that the statisticians found that weight loss differences between individual diets were small and likely of little importance. Their suggestion: if you want to lose weight adhere to any diet that you can stay on be it low-carb or low-fat.

The last article in the JAMA issue discussed two drugs, now on the market, that may aid and albeit weight loss: lorcaserin (Belviq) and Qsymia (Vivus). These new products are FDA approved for use in obese patients with body mass index (BMI) equal to or greater than 30 or overweight patients (BMI over 27) who also have at least one weight- related risk factor such as hypertension, abnormal lipids or type 2 diabetes.

In short: Belviq activates a serotonin receptor (type 2C to be exact) and is thought to suppress appetite. It can, however, cause headache, nausea and dizziness and in trials was discontinued 36 to 50% of the time. In the first year of one major trial, patients lost somewhat more that 5 % of their body weight but regained a quarter of it back during the second year of therapy. Qsymia combines phentermine and Topamax, a drug used for epilepsy. ( In the past phentermine was combined with fenfluramine (“phe-fen”) and caused heart valve problems…hence it was discontinued and now a new combination has been formulated, and felt to be heart valve safe.) Weight loss of 5% or more in the first year occurred in 45 to 70 % of patients depending on the dose and those who continued the medication for two years had an average weight loss of 10% compared to 1.8% in those on placebo. Side effects that occurred in more than 5% of patients included dry mouth, constipation, numbness and in the higher doses, insomnia. There were also reports of difficulties in concentration and memory.

In conclusion, the article states that either drug, taken as an addition to diet and exercise “may be affective in increasing weight loss in the first year of use, but much less so in the second year. Qsymia appears to be more effective than lovaserin, but may cause more troublesome adverse effects.”

A lot of information…I (or your other physicians) will be happy to discuss all of this in your next visit.

And I hope to see some of you (not in the office) October 6….

I quickly glanced at the first 2014 issue of JAMA before I returned to the office on January 2. And there was the first article to deal with weight… It was titled ” New obesity guidelines: promise and potential”. As we go back to our regular lives after the nutritional and alcohol excesses of the holiday, it seems most appropriate that we consider the major contributor to chronic disease: obesity. One in three US adults are obese.

There are new obesity guidelines to help physicians manage obesity more effectively. They were formed by an expert panel which first started their ponderous work in September 2008 and finally at the end of 2013 published what is now termed “Obesity 2″ guidelines for the management of overweight and obesity in adults. Here is a brief summary of their recommendations:

Recommendation 1 – Identifying patients who need to lose weight.

They continued to use BMI and waist circumference to identify those who are overweight or obese. An adult who has a BMI between 25 and 29.9 is considered overweight and an adult who has a BMI of 30 or higher is considered obese. Individual waist circumference is also important because abdominal fat is a predictor of risk for obesity-related diseases. If your waist circumference is more than 35 inches this adds to your risks from excessive weight. In general the greater the BMI and waist circumference, the greater the risk of cardiovascular disease, type 2 diabetes, and all-cause mortality.

Recommendation 2 – Counseling about the benefits of weight loss.

The panel stated that sustained weight loss of as little as 3 to 5% is likely to result in clinically meaningful reductions in levels of triglycerides, blood glucose, and hemoglobin A-1 C and in the risk of developing type 2 diabetes. Greater amounts of weight loss will reduce blood pressure, improve levels of low density and high density lipoprotein cholesterol, and reduce the need for medications to control blood pressure, blood glucose levels, and lipid levels as well as further reduce levels of triglycerides and blood glucose. The panel states that weight-loss can provide benefit for obese and overweight patients with only one additional risk factor and that one factor can simply be an increased weight circumference.

Recommendation 3 – Dietary therapy for weight loss.

The panel’s recommendations emphasize that there is no ideal diet for weight loss and that there is no evidence of superiority for any of the myriad diets they reviewed. Their primary recommendation is that a diet should achieve reduced caloric intake as part of a comprehensive lifestyle intervention (that includes exercise)

Recommendation 4 -Lifestyle intervention and counseling.

Obese or overweight individuals should enroll in comprehensive lifestyle interventions for weight-loss that should be delivered for six months or longer. The gold standard of therapy is on-site and high-intensity sessions (14 sessions or more in six months) provided in individual or groups by a trained interventionist. And further therapy should continue for a year or more. (They hope that payers will recognize the value of well-run programs that use this approach. They did state that lesser intensity approaches delivered electronically have not shown the same amount of weight loss and health benefits.)

Recommendation 5 – Bariatric surgery.

The Obesity 2 panel has advised practitioners to suggest to patients who are either obese with a BMI at or over 40 or at or over 35 with additional obesity related health conditions that they consider undergoing bariatric surgery by experienced bariatric surgeons.

Oy, this is a lot to consider for one third of our population. I was overwhelmed when I read this. I also lost my appetite for my next meal… But I thought I should share this with my patients and readers. Hopefully this will help to exhort all of us to maintain a lifestyle with appropriate caloric intake, and exercise in this new year.

We all know that Bacchus was a man. Based on gender stereotypes, most of us assume that women are less likely to excessively imbibe alcohol then men. (For the sake of transparency, the Superbowl was playing while I wrote this and all that celebrated testosterone caused me to make that last statement). But not necessarily so… According to a recent CDC report in “Vital Signs,” more than 14 million US women binge drink about three times a month and consume an average of six drinks per binge. This number includes one in eight women and one in five high school girls! The report states that binge drinking is most common in young women, women who are white or Hispanic, and among women with household incomes of $75,000 or more. Oh…and half of all high school girls who drink alcohol report binge drinking.

A woman’s ability to metabolize alcohol differs significantly from that of a man. When we drink alcohol it is absorbed more quickly, deactivated by enzymes less efficiently, and gets to the brain faster. (Well, we always knew that our brains have rapid and superior circulation. ) We generally weigh less than men so we are also less likely to dilute the stuff. As a result, one drink for a women has the impact of two for a man.

The definition of binge drinking for a woman is consumption of four or more alcohol drinks on an occasion. And an occasion is considered to be 2 to 3 hours. Although binge drinking in high school or college can lead to a higher incidence of alcoholism in later life, most binge drinkers are non-alcoholics and not alcohol dependent. The CDC reports that drinking too much (which of course includes binge drinking) results in about 23,000 deaths in women and girls each year and increases the chances of breast cancer, heart disease, sexually-transmitted diseases, unintended pregnancy as well as other health problems. If a woman binge drinks while pregnant, she risks exposing her baby to high levels of alcohol during its development which can lead to miscarriage, low birth weight, sudden infant death syndrome (SIDS), attention deficit/hyperactivity disorder (ADHD), and fetal alcohol syndrome (facial disfigurement and mental deficiencies). This is where I’m supposed to say it’s not safe to drink alcohol any time during pregnancy.

Aside from giving warnings, the CDC and its Guide to Community Preventive Services recommend certain strategies for preventing excessive alcohol consumption.. These include:  

*Increasing alcohol taxes.

*Reducing the number and concentration of stores that sell alcohol in a given area.

*Continuing government controls over alcohol sales.

*Maintaining or reducing the days and hours of alcohol sales.

*Enhanced enforcement of laws prohibiting sales to minors.

*Electronic screening and counseling for excessive alcohol use.

I know some of this sounds excessive and may go against our sense of what the government should and should not do. (There are no blue laws in California, and according to that wonderful series Boardwalk Empire, prohibition doesn’t work!) To help avoid teenage binging, the best plan might be to make sure that our teens can’t get into our liquor closet and of course, maintain zero tolerance for alcohol use before, during and after school parties. And then we should listen to the anti-binge advice ourselves. Remember abstaining from that second and certainly the third drink may lessen our risk for breast cancer, heart disease, stupid behavior, and worse yet, the wrong sexual and reproductive decisions. We just don’t need that extra glass of wine, cocktail or beer to enjoy the game, the dinner or the party. The salute ” Le Chaim” (translated, for those of you who need it) to “To Life” need not be accompanied by 4 drinks…one is healthier and should suffice.

A quick personal note: I am traveling to Mozambique next week with several women to see the school we built through the LA Associates of Save the Children. I will be happy to share pictures and stories upon my return.


I keep a mental dietary list which I review at the end of each day…”Let’s see, I had juice in the morning, salad at lunch, two vegetables at dinner and fruit for dessert. OK, now I’ve had my five or more fruits and vegetables and have done my nutritional duty to ward off cancer.” It turns out I am giving myself inadequately proven anti-cancer food advice.

The largest prospective study to date, the European Prospective Investigation into Cancer and Nutrition study (wisely acronymed the EPIC study), followed 478,478 individuals aged 25 to 70 years in 10 European countries for a median of 8.7 years. (How they got to a number that has those matching numerals is a mystery.) Unlike many large studies, women comprised the predominant gender (335,873 women vs. 142,605 men). The overall cancer incidence rates were 7.9 per 1000 person –years for men and 7.1 per thousand-person years for women. When the researchers analyzed the impact of daily veggies, they found that an increase of 100 grams (the equivalent of a serving of broccoli) reduced cancer risk by only 2% while a comparable intake of fruit (less than an apple) reduced cancer risk by just 1%. These were very low percentages…and were restricted to women; they didn’t even apply to men who gained no cancer protection.

I would like to remind you of a previous website article in which I cited articles that discourage women from drinking more than 10 grams (one drink) at any time. Well, the researchers that reviewed the EPIC data found that intake of fruit and vegetables did decrease cancer risk by 10% in heavy drinkers (more than 30 g daily for women and 60 grams for men). But considering all the damage that excessive alcohol consumption does to our health, proclaiming that the right foods will prevent certain cancers is not appropriate medical advice.

The American Cancer Society (ACS) still advises that we consume 5 servings of a variety of fruits and vegetables on a daily basis to help reduce cancer risk both directly as well as indirectly by helping maintain a healthy weight. In 2005, ACS made “the 5 rule” the third priority after healthy weight maintenance throughout life and adoption of a physically active lifestyle. The ACS meets to update its recommendations later this summer and will probably change them based on the EPIC study.

But before I encourage you to stop that “5-a-day” nutritional count let’s remember that cardiovascular disease is the number one cause of mortality in women (not cancer). There are many prospective studies that have shown that 5 servings of fruit and vegetables a day reduce cardiovascular risk by as much as 12%.  These foods contain nutrients and vitamins that are essential for all of our bodies’ functions. They most certainly help us maintain a healthy weight and a lower weight  (or more precisely, lack of obesity) will diminish our risk of diabetes, heart disease and many cancers. We have to eat something, and substitutions for fruits and/or veggies usually carry excess calories, sugar, salt and bad fats. (Think processed or junk food.)

I may stop computing those servings in the hope that I will reduce my risk of cancer, but I’ll keep up the count to maintain my heart, weight and future health and well being.

I routinely ask my new patients: “How much, on average, do you drink each week?” In order to make this question slightly less accusatory, I also add “do you usually have wine with dinner or a cocktail before?” If the answer is “yes, one or two glasses”, I then feel obligated to discuss the pros and cons of women’s alcohol consumption. I was therefore delighted to find an article under the heading of “Clinical  Crossroads” in last week’s JAMA which dealt with the question of whether a person (in this case, a 42 year old man) should drink for his health. The authors were kind enough to also consider the health implications of drinking for women. Here are some of the facts that they presented:

The estimated ethanol (alcohol) content per serving of various alcoholic beverages is similar, although their caloric content may vary. Twelve ounces of beer have 14 grams of ethanol and 150 calories, light beer contains 11 grams of ethanol but about 50 calories less; 5 ounces of wine contain 15 grams of ethanol and 120 -125 calories and finally 1.5 ounces of “hard alcohol” or spirits have 14 to 15 grams of ethanol and 100 calories.

Because women have a smaller volume of distribution in which to dilute the alcohol, overall smaller body size, and a different first –pass metabolism (alcohol is not as quickly metabolized by the liver), we experience the toxic effects of alcohol at approximately half the daily dose of alcohol as do men. One glass of  wine, serving of beer or “a drink” for a woman is like two for a man….so ( and I don’t meant to insult your intelligence, but  want to write this for emphasis)….two drinks at dinner would be the equivalent of four for a man. And that’s a number that would cause concern to most of their female companions.

Alcoholism has been ranked the third most important preventable cause of death in the United States. The National Institute on Alcohol Abuse and Alcoholism has issued the following guidelines for safe drinking:

* Up to 2 drinks for men younger than 65
* Up to one drink per drinking day (I’m not sure what constitutes a drinking day, but it’s their wording) for non-pregnant women and older adults

No alcohol for

* Women who are pregnant or trying to become pregnant
* Persons with medical conditions that could be made worse by drinking
* Persons who plan to engage in activities that require alertness and skill (such as driving a car)
* Persons taking certain over-the-counter or prescription medications (think sleeping medications, ant anxiety meds, antihistamines or anything that effects brazen chemistry)
* Persons recovering from alcoholism
*  Persons younger than 21

In order not to sound like an abolitionist, let me also proffer the data that was cited on the “biochemical effects of light to moderate alcohol consumption in short term feeding studies”. (Actually they were drinking studies). Researchers looked at certain biomarkers for cardiac disease and the effect of ethanol on these markers. HDL or high density lipoprotein (the good cholesterol) was minimally increased, but a lot of alcohol was needed to do this (60 grams per day in men and 35 grams in women). Alcohol seemed to work best on HDL if the levels were low to begin with. (Before menopause most women have fairly high HDL levels, perhaps due to their production of estrogen.) Triglycerides were increased in men who drank moderately but may have decreased in women (although beer with more carbohydrates seems to erase this phenomenon). Fibrinogen which is involved in clot production was lowered. Adiponectin which increases insulin sensitivity (a good thing) did minimally increase and as such may have lowered the risk of diabetes.

Now here is the concern for women: Light to moderate drinking increases the bodies own sex steroid hormones by 5% to 20% and can increase risk of breast cancer! This translates to an approximate 1% increase in the relative risk for each one gram a day of alcohol.   It also has an adverse effect on other cancers in men and women. Malignancies of the mouth, larynx and esophagus are increased in all moderate drinkers. The relative risk of developing these cancers (compared to nondrinkers) is approximately 1.4 to 1.7 with “just” 2 drinks a day.

So should we drink for our hearts or abstain for our breasts? Studies dating back at least 25 years have shown that 10 grams of ethanol per day among women (and 25 grams for men) lowered risk of coronary heart disease by 20 to 30%. The authors calculated that this conferred a 1% lower absolute 10 year risk for a 50 year old man who was deemed “average”, but remember our 10 year average risk at 50 is usually less than that of men.

It sounds like that one drink is a draw…but the authors go on to state that the typically high HDL levels in premenopausal women would appear to make any clinical benefit for alcohol limited at best, “and since the risk of breast cancer is increased, it is unlikely that premenopausal women would profit from drinking”.

There is so much more that we can do to prevent heart disease…not smoking, exercising, maintaining a reasonable body weight and if necessary treating elevated lipids (LDL cholesterol and triglyceride).

Alcohol is not a medicine. If you love it and want to drink a glass of wine with dinner or have that drink before….limit it to one.  Your choice to imbibe is similar to your desire for desert, but without the “nose”….it tastes good, you enjoy it and it adds to your meal. The toast “l’haim” (to life) that accompanies that drink is a wish, not a medical certainty.

We commonly use the adjective “sweet” to imply niceness….and of course the taste that has so domineered our palate. But the “added sugars” that help achieve the latter are anything but sweet to our hearts, brains or blood vessels. (I’ll refrain from using the word bittersweet.)  They are cloying together (my new term) to raise our bad cholesterol and enhance our demise from heart attack and stroke.

Our palate preferences have been fostered and exploited by the food industry. They know their market and have been happy to cater to our preferred taste for sweet by adding sugars in the form of refined beet or cane sugars and high-fructose corn syrup in processed or prepared food.

According to an article published in a recent Journal of the American Medical Association (JAMA), we ingest an average of 89.8 grams (21.4 teaspoons) or 359 calories of added sugar daily. This represents 15.8% of our total daily caloric intake and 31.7% of our total carbohydrate intake (as compared to just 10.6% in the late 70’s). These numbers were based on a study of adults who participated in the National Health and Nutrition Examination or NAHMES. (No, it wasn’t a pass-fail test and the subjects were not college students; as a matter of fact, they consisted of a “US civilian, noninstituitionalized population designed to obtain nationally representative estimates on diet and health indicators”). Individuals who were taking cholesterol- lowering medications and those with a diagnosis of diabetes were excluded. More than 6,000 adults were followed between 1999 and 2006; over half were women. (So we had due representation.) The participants were interviewed and gave a detailed 24 hour dietary recall. The nutrient content of the food they stated that they had consumed was determined by NAHMES from the US Department of Agriculture Nutritional Database as well as the MyPyramid Equivalents Database. (I guess a single source might have been questioned by the food industry.) The NAHMES investigators also collected fasting blood samples which they then tested for 3 lipid abnormalities: elevated triglyceride levels, elevated levels of small LDL-C particles and reduced HDL-C levels …all of which contribute to “dyslipidemia” (bad lipid levels that lead to coronary heart disease). So here is what they found:

  • A mean weight gain in one year of 2.8 pounds among those “extra sugar eaters” who consumed 25% or greater total energy from added sugar compared to a mean loss of 0.3 pounds among those who consumed less than 5% total energy from sugar.
  • In women who consumed more than 10% of their calories as added sugar, the odds that their good cholesterol or HDL-C  was low (think the stuff that acts as  a roto-rooter in your arteries) was 50 % to 300% greater than women who consumed less than 5% added sugar in their diets.
  • A higher level of triglycerides and a higher ratio of triglycerides to HDL-C in those who consumed more than that 10% of calories though sugar.

I know I am giving a lot of “higher” and “lower” numbers, but alas, that is what statistics are all about. Put simply, the higher your intake of “added sugar” the more likely you will gain weight and ruin your good and bad lipid levels. It’s not enough to just eat low fat or abstain from the wrong fats in order to maintain an internal cholesterol and fat ratio that will protect your blood vessels, heart and brain. You have to abstain from ubiquitous “added sugars”. Check the labels on those sodas, coffee drinks, canned food, cookies, soups, cereals, breads or anything that is processed. (And the term “naturally sweetened” doesn’t mean that the sugar is exempt from the above.). Your overall “added sugar” should not be higher than 100 calories a day or 5% of your caloric intake. There is nothing sweet about the wrong fats that clog vessels and result in heart attack and stroke.

Most of us plan our medical appointment based on symptoms and complaints, need for check up, schedule and of course, the availability of our physician or health care practitioner. There are only so many early morning openings, and these may be further diminished when doctors make hospital rounds and/or perform surgeries before arriving at the office. If you don’t want to leave home without breakfast in the morning or you have to make a late afternoon appointment, you may not be willing or able to fast for blood tests. (I encourage everyone to eat their breakfast…I won’t leave home without it. This may be the time to mention that individuals who don’t eat breakfast have a shorter life span….fasting from dinner until lunch will result in an overly aggressive i.e., high, insulin response to the delayed meal. Elevated insulin levels can cause fat to accumulate in unwanted places and increase the risk of cardiovascular disease.)

So there you are at the doctor’s office, you have not fasted and you are told that the blood test for diabetes (and perhaps heart disease) can’t be done…Thus is no longer inaccurate. An article just published in the March 4 issue of The New England Journal of Medicine reported that a non fasting blood test called glycated hemoglobin (also known as hemoglobin A1c) will diagnose risk of diabetes just as well or better than a fasting blood sugar (glucose) test and can also strongly indicate risk of cardiovascular disease and death from any cause!

Until recently, the standard measure used for diagnosis of diabetes was a fasting blood sugar. Glycated hemoglobin is a test that reflects your previous 2 to 3 month exposure to glucose and will include spikes that occur after eating. It doesn’t vary from hour to hour or day to day and is not dependent on what you just ate. It is essentially the glucose “truth meter” for what you have consumed and your blood glucose response over the past few months. It has traditionally been used for the determination of glucose control among those who have already been diagnosed with diabetes and are on therapy. But this and other reports will eventually make glycated hemoglobin the test “of choice” for diagnosis and assessment of diabetic risk in everyone.

The Atherosclerosis Risk in Communities (ARIC) is a community -based prospective study of middle-aged adults from four U.S. centers. It was started in the late 80’s and continues to present time. During the study, the researchers measured the glycated hemoglobin in blood samples from 11,092 adults who did not have a history of diabetes or cardiovascular disease. More than 55% of those tested were women. Their ages ranged from the mid-forties to mid-sixties. For the individuals who were found to have glycated hemoglobin of 6.0 to 6.5%, the risk of diabetes (the technical term was multi-variable-adjusted hazard ratio) was 4.48. (Those who had values of 6% to 6.5% were 4.48 times more likely to develop diabetes then individuals used as a reference who had glycated hemoglobin of less than 5.5%). For those individuals who had a level greater than 6.5% the risk was 16.47. The researchers then checked to see who developed coronary disease and stroke. The hazard ratio for a value of 6 to 6.5% was 1.76 and over 6.5% was 1.95 (or a 95% increase over those with low glycated hemoglobin levels.) They also looked at death from any cause and found that the higher the glycated hemoglobin, the greater the risk of mortality. Moreover glycated hemoglobin levels were found to be more predictive of disease than fasting blood sugar levels.

Studies have show that among people in the United States who do not have a diagnosis of diabetes, over 2.4 million have a glycated hemoglobin higher than 6.5% and 7 million have a value higher than 6.0%. This is an ill inspiring number.

Bottom line: A non-fasting blood test for glycated hemoglobin can help determine whether you are at risk for development of diabetes, cardiovascular disease and even early death. Hopefully it will be less than 6.0%. Most of us now know our cholesterol and lipid levels; it may be just as important to know your glycated hemoglobin level. If it’s too high you and your doctor will need to discuss the necessary behavioral changes and therapies that will help you to maintain your health.

Once upon a time most of us moved here, to LA, from other states or countries. And we love it!  As veteran Los Angelinos we live, work and of course, look at others in this, our youth and media oriented city. The inevitable follows: we would like to look like a celebrity worthy of an appearance on Oprah or at least appear younger than our chronologic age. So when we see ads politely inquiring whether we are developing a bulge above our jeans, flushing, flashing (from heat, not exhibitionism), sleeping poorly, loosing our libido or worse… wrinkling; we go on the alert. Who can resist that spiel? : Step right up and spit here; we’ll see what you’re missing and order you a very special, made- just- for- you therapy. Rub this cream on, swallow these capsules, put these drops under your tongue and don’t worry, these “bioidentical” hormones are chockfull of health, not like the ones made by those big, bad pharmaceutical companies.

Many of my tenured (note I refrain form using the adjective “old”) and new patients want to know if they should start these “bioidentical” hormones or switch to them.  To quote Shakespeare, who was hormonally clueless but recognized some distressing female symptoms:  Here’s the rub.

“Bioidentical” is a marketing term. It’s as ingenious as the word natural when it comes to selling a product; both appeal to consumers’ aversion to artificial ingredients. But remember, hemlock is natural.

When the term “bioidentical” is used by compounding pharmacies and celebrities who are often selling their products or touting their own books, it refers to formulations of various types of estrogens, progesterone, adrenal hormones, and androgens (male hormones) compounded within creams, gels, lotions, capsules, drops, capsules, and even suppositories.  The compounded estrogens are often a combination of weak forms of estrogen (estrone or estriol) as well as the stronger  estradiol. In order to get significant relief of menopausal symptoms, large doses of the estriol or estrone   have to be used and there is no evidence that this is safer than the lower dose of estradiol which, by the way, was produced by our ovaries and accepted by nearly every cell in our bodies during our reproductive years. Estradiol is the estrogen contained in many of the FDA approved hormone therapy medications, and/or the metabolite (the end result after processing in the body) of these medications.  Nearly all plant derived estrogen therapy, both individually compounded formulations and pharmaceutical products come from the same soy and yam precursors. They all undergo chemical conversion to become hormones. ( The concept of plant gathering followed by stomping created a great “I Love Lucy” sketch and will work for grape juice and ultimately wine, but will not result in a biologically active hormone product, no matter how skillful the stomping and crushing.) Compounding pharmacies may claim that the combination of their estrogens is either safer or more natural than any of the products that are commercially prepared by pharmaceutical companies. No clinical studies published in reputable peer review journals have shown this to be true. As for the claim that estriol may reduce the risk of breast cancer; this is pure speculation based on old studies that were usually carried out on animals. The FDA has unequivocally stated that it is not aware of any credible scientific evidence to support claims made regarding the safety and effectiveness of compounded “bioidentical” hormone replacement drugs. They have taken action against seven pharmacy operations that claim their compounded “bioidentical drugs” which contain hormones such as estrogen, progesterone and estriol are superior to FDA-approved menopausal hormone therapy medications. The American College of Obstetricians and Gynecologists (my professional entity) has the same concerns stating that “most compounded products have not undergone rigorous clinical tasting for safety or efficacy and issues regarding purity, potency and quality”.

Doctors who prescribe these “bioidentical” hormones often use salivary (spit) testing to tailor the amount of hormones they prescribe. But salivary hormone levels vary tremendously throughout the day and differ from woman to woman. Moreover we don’t have studies that demonstrate a correlation between the levels of spit hormones and a woman’s clinical state or her response to hormone preparations. The major mavens on menopause (we have a society for everything), The North American Menopause Society, does not recommend saliva testing to determine hormone levels, nor do they recommend custom compounded products over “well tested, government approved products for the majority of women”. All these institutions are concerned that patients do not see the black box warnings that are prominently displayed with FDA approved medications…the ones that state that hormones should not be used if you have had certain conditions that include estrogen related cancers and blood clots and the concerns about risks for long term use.

Finally who pays? Sometimes insurance companies do, but often the patient is stuck with a bill that is higher than the one she would pay (or co-pay) for commercially prepared hormones. Moreover if the practitioner who prescribes “bioidentical” hormones also sells them from her or his office, there is a potential conflict of interest.

Some hormones including testosterone and DHEA (used for low libido or specific deficiency disorders) may not be available in pharmaceutical products and will have to be compounded. As a matter of full disclosure, I do prescribe compounded hormones when the latter are needed or when a patient becomes allergic to standard therapy. But I advise all my patients that there are no free hormones, no matter how they are made. There is an indication and contraindication to every medication and it’s imperative that your physician use appropriate, up-to-date studies in order to inform you of both.

Unfortunately, no hormone will provide you with that lost fountain of youth. But when prescribed for significant symptoms in appropriate doses, hormone therapy will help you feel better. Exercise, proper nutrition, weight control, hair color, make-up, and the right lighting are the only proven (and risk free) ways to help you feel and look your best.


The word epidemic is tossed around by the media quite easily…. it’s a scary word that sells news. Unfortunately it doesn’t always sell individual health care. The incidence of diabetes is rising to such an extent that it unfortunately warrants the term “epidemic”. Most concerning is the statistic that up to 40% of people with diabetes are not diagnosed! The principal reason (aside from the fact that they don’t go to a health care facility until they are really sick) is that screening usually requires a fasting blood test. If a visit is postprandial (a fancy medical way of saying after eating) a blood sugar test is often postponed for another don’t eat for 8 hours time, and subsequent noncompliance or busy schedules mean that there is a  good chance that it won’t be done at all.

Before I get to the “easier” test I must perform my public health duties and give you the scare the sugar out of us statistics from the American Diabetes Association:

  • 20.8 million Americans or 7.0% of the population had diabetes in 2005
  • 14.6 million were diagnosed
  • 6.2 million were undiagnosed
  • 51 million people aged 40 to 74 have impaired glucose tolerance (considered to be a pre-diabetic condition), impaired fasting glucose level ( it was high) or both.


  • 5 to 10%, of those with diabetes have type 1 (insulin dependent)
  • 90 to 95% have type 2 (not insulin dependent, latter age onset, associated with obesity, heart disease and to sum it up…early onset of death)
  • Within the next 3 decades the number of people with diabetes is projected to double (to 366 million people); as the population ages, expands (literally and figuratively), eats more, exercises less and become obese.

Now, for the diagnostic good news: There is a blood test called hemoglobin A1c (HbA1c), also called glycelated hemoglobin, that reflects the status of your blood sugar in the previous 2 to 3 months. As you know hemoglobin carries the oxygen in your blood cells. It also links to excess sugar in a process called glycelation. The more your blood sugar levels rise, the more your hemoglobin becomes glycelated. The HbA1c test has become standard in “telling” whether glucose control has been adequate in individuals treated for diabetes. Now many experts feel that the test can be used in lieu of a fasting blood sugar to screen everyone. It “can see” if diabetes is developing in otherwise undiagnosed adults and children. (Unfortunately we have also seen an increase in Type 2 diabetes in adolescents and children over the last decade).  If HbA1c is higher than 6.0%, further testing should be done to check for diabetes. If it is 6.9 or higher, a diabetes diagnosis is highly likely and therapy warranted.

Bottom line…this is a simple blood test that would benefit all those with any risk factors for diabetes including:

  • Women who have had gestational diabetes
  • Women with a history or diagnosis of polycystic ovarian syndrome ( which may cause irregular periods, fertility problems, obesity, abnormal hair growth, acne and/or elevated blood triglycerides)
  • A family history of diabetes, obesity, hypertension and early heart disease
  • Obesity
  • Hypertension
  • Elevated lipids
  • Coronary heart disease

There are so many common and shared risks for diabetes that most of us might benefit from knowing our HbAIc level.